Referral Form

REFERRAL FORM       Date: ___________ Work Comp? Yes / No

Patient Name: __________________________________ Phone: ____________

DOB: __________ Diagnosis: ________________________________________ 


___   2 Day FCE-
 Up to 2 hours on the first day and up to 3 hours on the second day.  
  Includes around 20 relability indicators.

___   1 Day FCE- Up to 4 hours in one day.  Includers around 12 reliability indicators.

___   Disability FCE-  Approximately 2 hours of testing in 1 day specifically designed
  to answer the questions on the Social Security Disability form. 

___   OT Eval for Restrictions / Brief FCE- Up to 1.5 hours of testing with some
reliability indiators.  Useful for filling out restriction forms.


___   Work Hardening/Conditioning Therapy

___   Occupational Therapy

___   Ergonomic Evaluation 

Physician's Signature:  ___________________________________________

Printed: ________________________

Physician's Office Contact: ________________________________________________  

Physician's Contact Phone #: _______________________

FAX TO: (920) 497-1513,
Pease include pertinent physician notes and billing info.

CALL: (920) 497-1515
to ensure we received the referral.  Voice mails are
returned promptly. Appointments are usually available within days.